General Medicine #2 Flashcards
1
Q
Causes of Mitral Regurgitation?
A
Leaflet:
- Congenital
- Endocarditis
- Degenerative
Papillary muscle (MI/Marphans)
Dilatation
- Cardiomyopathy
- IHD
2
Q
Signs of Mitral regurg?
A
Displaced apex beat (volume overload)
Quiet first heart sound
Pansystolic murmur - radiates to axilla
3
Q
Two common valvular disorders secondary to rheumatic heart disease?
A
Aortic regurgitation
Mitral stenosis
4
Q
Coarse of disease in Rheumatic Heart Disease?
A
Group A strep throat infection
2/4 weeks later = Acute Rheumatic Fever
Over 10-20 years there is repeated sub-clinical episodes, and/or autoimmune processes
then you get chronic rheumatic HD leading to leaflet thickening and fusion of commissures
- Mitral stenosis
- Aortic regurg
5
Q
Features of mitral stenosis
A
Mid diastolic murmur
Loud first heart sound
- As blood is not freely flowing from left atrium the high pressures keep the valve open and then systole slams it shut = loud sound
Opening snap
Malar flush
AF
6
Q
What’s the course of disease that results in Right heart failure in mitral stenosis?
A
High Left atrial pressure leads to…
high pulmonary pressure, which leads to…
Right ventricular hypertrophy…
Tricuspid regurgitation…
Right heart failure.
7
Q
Causes of Aortic regurg (REALM)?
A
Rheumatic heart disease
Endocarditis
Ankylosing spondylitis
Leutic HD (tertiary syphilis)
Marphans
8
Q
Is the apex displaced in Aortic regurg?
A
Yes - Volume overload
9
Q
Features needed for ACS diagnosis?
A
Cardiac chest pain
Troponin
ECG changes
- T wave inversion
- ST elevation/Depression
- Q waves
- New LBBB
10
Q
Investigations in cardiac ischaemia, and justification?
A
BOXES
Bloods
- FBC - anaemia can cause ischaemia
- U&Es - Impaired renal function - false positive trop. Hypo and Hyperkalaemia.
- Glucose - diabetic - aim for 4-11
- LFTs, baseline prior to statins
- Lipids
Serial trops
CXR
ECG
??Angiography/PCI
11
Q
What is a good way to think of STEMI management (Dr Clarke)?
A
Immediate management - MONA
- Morphine (& metoclopramide)
- O2 if <94%
- Nitrates (GTN sublingual)
- Aspirin 300mg stat
Cardiology
- PCI (or if >12hrs Alteplase)
- Ticagrelor or clopidogrel loading dose (also IV hep or LMWH)
- Angioplasty and stenting
Further preventative management (ABCDE)
- ACE I
- B-Blocker
- Cholesterol lowering statin
- Dual antiplatelets
- Echo to assess left ventricular function
12
Q
Maintenance antiplatelet regime following STEMI?
A
Clopidogrel 75mg daily OR Ticagrelor 90mg for 1 year
Aspirin 75mg daily indefinitely
13
Q
Apart from ST elevation what other 2 sets of changes on the ECG are treated in the same way?
A
New LBBB
Posterior infarct (ST depression & R waves in V1 and V2)
14
Q
Good way to think of NSTEMI/Unstable angina management?
A
Immediate (MONA)
- Morphine (& metoclopramide)
- O2 is sats <94
- Nitrates sublingual
- Aspirin 300mg stat
All patients (three things)
- Aspirin 300mg
- Nitrates or morphine to relieve chest pain if required
- Clopidogrel 300mg
Then three things to consider:
- Coronary angiography
- should be considered within 96 hours of first admission to hospital to patients who have a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in patients who are clinically unstable.
2 .Antithrombin treatment.
- Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a patient’s creatinine is > 265 µmol/l unfractionated heparin should be given.
- Intravenous glycoprotein IIb/IIIa receptor antagonists
- (eptifibatide or tirofiban) should be given to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.
15
Q
Presentation of patient in Acute LVF?
A
Inspection
- Looks acutely unwell
- Cold, clammy peripheries
- Frothy blood stained sputum
- Orthopnoeic, using accessory muscles
- ?Wheeze
Obs
- Tachycardia
- Hypotension
Examination
- Cardiomegaly - displaced beat, valve disease
- 3rd and 4th Heart sounds
- Right sided or bilateral pleural effusions
16
Q
Radiographic changes in acute LVF?
A
- Cardiomegaly
- Upper lobe diversion
- Diffuse mottling of lung fields
- Prominent hilar shadows (bat wing appearance)
- Pleural effusions
Fluid in fissures
17
Q
Investigations in acute Left ventricular failure?
A
BOXES
Bloods
- FBC - exclude anaemia
- U&Es - monitor renal function (with view to using diuretics)
- Blood glucose - diabetes
- BNP - SINGLE MEASUREMENT RAISED CONFIRMS DIAGNOSIS
- ABG
- Trop
Orifices
- NA
XRAY
- CXR
ECG
Special
- Echo
18
Q
Causes of acute Left ventricular failure?
A
CHAMP
Coronary syndrome
Hypotensive emergency
Arrhythmia
Mechanical
- Valve
- VSD
- LV aneurysm
PE
19
Q
Acute management of acute LVF?
A
A-E assessment
- Secure airway if needed, consider O2
Sit patient up
15L hi flo by non-rebreathe
Drugs
- 40mg Furosemide IV
- IV GTN/Isosorbide mononitrate (If systolic >90)
- Consider inotropes (>90 systolic)
- Consider ITU
- Opiates if chest pain
Escalate - Cardio/ITU
20
Q
4 Indications for a permanent pacemaker?
A
SA nodal disease (Sick Sinus Syndrome)
Symptomatic 2nd or 3rd degree Heart block
AF with slow Ventricular rate, or refractory AF
Cardiac resynchronisation in HF
21
Q
Investigations of infective endocarditis?
A
BOXES
Bloods
- FBC (WCC)
- ESR/CRP
- Blood cultures (3 sets)
Orifices
- Urine dip
X
- CXR
ECG
Special
- echocardiogram
22
Q
Presentation of AKI, in terms of obs and bloods?
A
Rise of creatinine >= 50% within 7 days
<0.5mg/kg/hr (<30) urine output
23
Q
Which drugs need to be stopped in AKI?
A
The DAAMN Drugs
Diuretics
ACEI
ARII
Metformin
NSAIDS
24
Q
Causes of CKD?
A
HIDDEN
HTN
Infection
Diabetes
Drugs
Exotic stuff - SLE and Vasculitis
Nephritis - Glomerulonephritis
25
At what point do you start to treat Aortic Stenosis?
Symptoms and > ABOVE 40mmhg aortic valve gradient
26
What are the points on the CHA(2)DS(2)VASc(S) score
Congestive HF - 1 point
Hypertension - 1 point
Age - 1 if above 65, 2 if above 75
Diabetes - 1 point
Stroke or TIA - 2 points
VASc - Prev. Vascular disease - 1 point
Sex - 1 point for female
27
Anaphylaxis immediate drug management?
500micrograms adrenaline 1 in 1000
200mg hydrocortisone
10mg chlorphenamine
28
What would papillary muscle rupture secondary to MI look like?
ARRHT
Acute Mitral regurg - Pansystolic murmur
Reduced volume pulse
Raised JVP
Hypotension
Tachycardia
29
Drug treatment for torsades des pointes?
Magnesium sulphate IV
30
What is the management of peri-arrest tachycardias?
Broad complex regular
- Assume VT
- DC cardioversion if haemodynamic instability
- Amiodarone if not
Broad complex irregular
- AF with BBB (treat as if AF)
- Torsades Des Pointes (IV Mag sulf)
Narrow complex regular
- SVT
- vagal manoeuvres followed by IV adenosine
Narrow complex irregular
- AF
- Cardiovert if <48hrs, rate control if not
31
What is the most common congenital cardiac defect to be found in adulthood? How do they present?
ASD
Ejection systolic murmur (split S2)
Embolism may pass from venous side to cause a stroke
32
At what QRISK do you prescribe statins?
>10%
33
What is a bisferiens pulse associated with?
Aortic valve disease
HOCM
34
How long is the QT normally?
10 small boxes (2 big squares)
35
Where are keloid scars most likely to form?
Sternum
36
What area of the skin do pemphigoid antibodies taret?
Desmosomes (the things that join the cells together)
37
What is erythroderma? What are the causes?
A rash that involves 95% of the skin
Causes:
- eczema
- psoriasis
- drugs e.g. gold
- lymphomas, leukaemias
- idiopathic
38
Pharmacological treatment of scabies?
permethrin 5% is first-line
malathion 0.5% is second-line
Pruritus can persist for up to 6 weeks after treatment
39
Psoriasis management?
- Regular emollients
1. First-line: Potent corticosteroid applied OD plus vitamin D analogue applied OD (applied separately) for up to 4 weeks.
2. Second-line: if no improvement after 8 weeks then offer a vitamin D analogue twice daily
3. Third-line: if no improvement after 8-12 weeks then offer either: a potent corticosteroid applied twice daily for up to 4 weeks or a coal tar preparation applied once or twice daily
- Short-acting dithranol can also be used
40
What is Leukoplakia?
Leukoplakia is a premalignant condition which presents as white, hard spots on the mucous membranes of the mouth. It is more common in smokers.
41
What is Lentigo Maligna? How does it present?
Lentigo maligna is a precursor to lentigo maligna melanoma. It begins as a suspicious flat freckle which can grow over 5-20 years to develop into melanoma.
Sun exposed skin.
Like a melanoma - key think is slow growth, like a melanoma.
42
What is Necrobiosis lipoidica diabeticorum, how does it present?
- Shiny, painless areas of yellow/red skin typically on the shin of diabetics
- Often associated with telangiectasia
43
What colour ca actinic keratoses be?
May be pink, red, brown or the same colour as the skin
44
What are curlings ulcers?
Stress ulcers in burns patients. Can bleed.
45
How can Acral lentiginous melanoma present?
Hutchinsons sign - nail bed
Enlarging discoloured skin patch on the palms, fingers, soles or toes with the characteristics of other flat forms of melanoma
46
Causes of acute addisonian crisis?
1. Sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison's, Hypopituitarism)
2. Adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia)
3. Steroid withdrawal
47
What is the bug in rheumatic fever?
Strep Pyogenes
48
Cardiac drug typically associated with angiodema?
ACEI
49
How long does a mouth ulcer have to be there to warrant a 2ww cancer pathway referral?
3 weeks
50
What is Ludwigs Angina? How does it present?
Cellulitis at the floor of the mouth, presents in patients with poor dentition who are immunocompromised (IVDU).
Pts get malaise, fever and dysphagia progressing to airway obstruction.
51
What is Sialolithiasis and Sialadenitis?
Sialolithiasis
- Stones in Whartons duct
- Pts get facial pain, and swelling of the submandibular gland
Sialadenitis
- Post-staph aureus infection
- May see pus
- Can get submandibular abscess
52
What are stensens duct and whartons duct?
Stensen's duct is in the Parotid
Wharton's is the submandibular, W = Lower down
53
Management of sudden onset sensorineural hearing loss?
Urgent ENT referral and High dose steroids
54
What cardiac abnormality is acromegaly associated with?
Cardiomegaly
55
What is Acute Necrotizing Ulcerative Gingivitis (ANUG)? Management?
On a spectrum of disease from simple Halitosis to ANUG.
Painful bleeding gums with halitosis and punched-out ulcers on the gums
Management:
- Paracetamol
- Chlorhexidine mouthwash
- Metronidazole
- Refer to dentist
56
Management of a pituitary adenoma
Depends on type
Prolactinoma
- Bromocriptine
Micro/Macro
- Definitive is neurosurgery
- Micro has better success rates
57
What is a Sistrunk's procedure for?
Thyroglossal cyst.
58
How does MODY (diabetes) present? Management?
T2DM in those <25 y/o, FH.
Manage with Sulphonylureas.
59
Causes of a raised prolactin?
Pregnancy
Prolactinoma
Physiological
Polycystic ovarian syndrome
Primary hypothyroidism
Phenothiazines, metocloPramide, domPeridone
60
What is C peptide, how does it normally react to exogenous insulin? If this is abnormal, likely diagnosis? What is it like in T1 and T2 DM?
C peptide is produced when insulin is produced, so when exogenous insulin is given it should fall.
If it does not fall - insulinoma
It is low in T1DM
It is normal/high in T2DM
61
What is Whipples triad for insulinoma?
Symptoms and signs of hypoglycemia
Plasma glucose < 2.5 mmol/L
Reversibility of symptoms on the administration of glucose
62
Causes of gingival hyperplasia?
Phenytoin
Ciclosporin
Calcium channel blockers
AML
63
Palpable abdominal mass in child (<15 y/o) warrants what management option?
48 hour referral to secondary care to exclude wilms tumour of nephroblastoma
64
Management of addisonian crisis?
Hydrocortisone 100mg IV/IM
1L N Saline over 60 mins (w/ dextrose if hypoglycaemic)
65
If a postmenopausal woman has suffered a fracture, what is the management plan?
Treat as osteoporosis
- Risendronate and calcium supplementation
66
What is erythrasma? Treatment?
Erythrasma is a generally asymptomatic, flat, slightly scaly, pink or brown rash usually found in the groin or axillae.
Topical miconazole/antibacterial
Or ORAL erythromycin (if extensive)
67
Orlistat mechanism of action?
Pancreatic lipase inhibitor
(lose weight)
68
Management of actinic keratoses?
1. Prevention of further risk: e.g. sun avoidance, sun cream
2. Fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation
3. Topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects
4. Topical imiquimod: trials have shown good efficacy
cryotherapy
5. curettage and cautery
69
How many skin types are there?
1-6
70
How do you differentiate between a Cystic hygroma and a Branchial cyst?
Cystic Hygroma
- Present at birth
- Transilluminates better than branchial
- POSTERIOR triangle, multilobulated
Branchial cyst
- Fluid has Cholesterol
- Usually transilluminates
- Teens/young adults
- Anterior triangle, at level of the hyoid.
71
PE typically causes what pattern on ABG?
Respiratory alkalosis (hyperventilation)
72
What syndrome is associated with coarctation of the aorta?
Turners
73
ECG changes in hypothermia?
bradycardia
'J' wave - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias
74
Management of acute and prophylaxis of variceal haemorrhage?
Propranolol for prophylaxis
Acute - terlipressin
75
Presentation of villous adenoma?
Non-specific lower gastrointestinal symptoms
Secretory diarrhoea may occur
Microcytic anaemia
Hypokalaemia
76
What is Plummer-Vinson Syndrome? Triad?
Rare disease, unknown cause
Triad of:
- Dysphagia (secondary to oesophageal webs)
- Glossitis
- Iron-deficiency anaemia
77
Treatment in acute pheochromocytoma?
Phenoxybenzamine
78
How do you treat VT?
Haemodynamically unstable
- Synchronised DC cardioversion
Haemodynamically stable
- IV amiodarone
79
What is the starting regime for newly diagnosed Type 1 diabetics?
basal–bolus using twice‑daily insulin detemir
80
What murmurs are a VSD, ASD and Tetralogy of Fallot associated with?
VSD
- Pansystolic
ASD
- Ejection systolic, split s2, heard at the back
Tetralogy of fallot
- Ejection systolic
81
What diabetic medication increases risk of osteoporosis?
Thiazolidinediones
82
Management of acne rosacea?
mild/moderate: topical metronidazole
severe/resistant: oral tetracycline
83
In arteriovenous fistula which vein is usually connected to he radial artery?
The cephalic vein
84
Why do long term dialysis patients need a AV fistula?
Easy access to high flow, high pressure arterial blood
85
Apart from an AV fistula what two other methods could you use for dialysis?
Drawbacks?
Dual-lumen tunneled catheter, centrally placed (for AKI mostly)
- Drawback is a high recirculation rate
Peritoneal dialysis
- Risk of infection
86
What questions can you ask to assess someone's CKD symptoms?
1. What are your energy levels like?
2. Do you get breathless?
3. Do you suffer from itching? (pruritis)
4. Bone pain, or gout?
5. Numb or tingling feeling? (parasthesia)
87
Three common causes of tiredness (Dr Clarke)?
Anaemia
Solute retention (CKD)
Psychosocial
88
Three common causes of breathlessness (Dr Clarke)
Anaemia
Fluid overload (e.g.CKD)
heart failure
89
Why does CKD lead to peripheral neuropathy?
Retention of beta-2-microglobulin
Diabetes is a common cause of CKD
90
Features of CKD (mnemonic)?
BIG BEAN
Breathlessness
Itching
Gout
Bone pain
Energy low
Ankle swelling
Neuropathy
91
Features of Nephrotic syndrome?
Proteinuria (>3g in 24hrs)
Hypoalbuminaemia (<30g/dl)
Oedema (loss of protein oncotic pressure allows salt and water into ECF)
Hypercholesterolaemia (liver synthesised more cholesterol)
92
Main cause of nephrotic syndrome in children?
Minimal change disease often Idiopathic (steroid responsive)
93
Main cause of nephrotic syndrome in adults?
Glomerulosclerosis - especially due to diabetes
Membranous glomerulonephritis (usually idiopathic)
Amyloidosis
94
Treatment of nephrotic syndrome?
Diuretics and salt restriction for oedema
Minimal change - Steroids +/- cyclophosphamide
ACEI (reduced protein excretion)
Anticoagulation (there is hypercoagulation)
Statins
95
Features of acute nephritis/Acute nephritic syndrome?
Abnormal HOST response?
Hypertension
Oliguria
Smoky brown haematuria with casts
Trace of oedema
96
Causes of acute nephritic syndrome?
Post strep
IgA nephritis
Vasculitis - SLE
97
Special investigations in acute nephritis?
Throat swab
ASO titre
24hr urinary protein
98
Treatment of acute nephritis?
Penicillin in Streptococci present
Salt restriction and anti-hypertensive drugs
99
What is glomerulonephritis, what is it made up of roughly?
Basically any condition that leads to inflammation of the glomerulus or the nephrons
Divided up into roughly nephrotic presentation or nephritic presentation.
100
What is haemolytic uraemic syndrome? Presentation? management?
Triad of:
- acute renal failure
- microangiopathic haemolytic anaemia
- thrombocytopenia
Occurs commonly in young children, after dysentry
Management is supportive
101
Features of Dominant PCKD?
Hypertension
Recurrent UTIs
Abdominal pain
Renal stones
Haematuria
CKD
Has extra-renal manifestations causing
- Berry aneurysms - SAH
- Liver cysts (also pancreas, spleen)
102
What are the main causes of a normal anion gap metabolic acidosis?
Dehydration
Addisons
Renal tubular acidosis
103
What is goodpasture's syndrome?
Anti-glomerular basement membrane antibodies against type IV collagen. More common in men.
Presents with:
- Pulmonary haemorrhage
- Followed by rapidly progressive glomerulonephritis
104
Differences in presentation of IgA nephritis and Post-strep glomerlulonephritis
IgA
- 1-2 days after URTI
- Large macroscopic Haematuria
Post-strep
- 1-2 weeks after
- Proteinuria
Both can be associated with haematuria
105
How does Recessive PCKD present?
Normally in very young children or within the womb. Newborn children may have potter's syndrome (due to oligohydramnios)
106
What is the mode of inheritance of alports syndrome, how does it present?
X linked dominant
1. microscopic haematuria
2. progressive renal failure
3. bilateral sensorineural deafness
4. retinitis pigmentosa
5. lenticonus: protrusion of the lens surface into the anterior chamber
Renal biopsy: splitting of lamina densa seen on electron microscopy
107
What is Renal papillary necrosis?
How does it present?
What are it's causes?
Renal papillary necrosis describes the coagulative necrosis of the renal papillae due to a variety of causes.
Presentation:
- visible haematuria
- loin pain
- proteinuria
Causes
- pyelonephritis
- diabetic nephropathy
- obstructive nephropathy
- analgesic nephropathy
- sickle cell anaemia
- Acute interstitial nephritis
108
What are the differences between the two types of autosomal dominant polycystic kidney disease?
Type 1
- Chromosome 16
- More common (85%)
- Presents earlier
Type 2
- Chromosome 4
- 15% of cases
109
What does fanconi syndrome result in?
Type 2 (proximal) renal tubular acidosis,
Rickets/osteomalacia
Polyuria
110
What is Membranoproliferative glomerulonephritis (IgA)? Overview?
Also known as mesangiocapillary glomerulonephritis or IgA nephropathy
May present as nephrotic syndrome, haematuria or proteinuria.
Associated with subcut tissue loss from face
Poor prognosis
111
First option for renal replacement in independent patients?
First option is peritoneal dialysis, if not contraindicated (abdo pathology)
112
Mainstay treatment in rhabdomyolysis?
IV fluid resus (normal saline)
113
What is Dialysis disequilibrium syndrome?
Dialysis disequilibrium syndrome is a rare complication and usually affects those who have recently started renal replacement therapy. It is caused by cerebral oedema,
114
WHat type of syndrome does proliferative and non-proliferative glomerulonephritis cause?
Generally proliferative glomerulonephritis causes nephritic syndrome and non-proliferative glomerulonephritis causes nephrotic syndrome
115
How do you calculate the anion gap?
([Na+] + [K+]) - ([Cl] + [HCO3]) Normal is 8-14
116
What type of AKI causes proteinuria?
Intrinsic only
117
Normal range for anion gap?
8-14
118
What rise in Creatinine and Fall in eGFR is acceptable following CKD treatment with ACEI?
NICE suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable
119
How do you screen for diabetic nephropathy?
all patients should be screened annually
albumin:creatinine ratio (ACR) in early morning specimen
ACR > 2.5 = microalbuminuria
120
Diabetes insipidus gives what result on the plasma and sodium osmolality?
Diabetes insipidus is characterised by a high plasma osmolality and a low urine osmolality
Not enough ADH/not responding
SO can't concentrate the urine to shift the concentrated Na+ in the plasma.
Aquaporins are there to draw the water out na concentrate the urine so that plasma osmolality can be reduced
121
Presentation of renal cell carcinoma?
Classical triad: haematuria, loin pain, abdominal mass
Can also get pyrexia and left varicocele
122
Common cause of bacterial otitis media?
Haemophilus influenzae
123
In dehydration the rise in urea or creatinine is higher?
Urea is much higher
Creatinine is high in AKI
124
Complications of nephrotic syndrome?
1. Increased risk of infection due to urinary immunoglobulin loss
2. Increased risk of thromboembolism related to loss of antithrombin III and plasminogen in the urine. This may result in a renal vein thrombosis, resulting in a sudden deterioration in renal function.
3. Hyperlipidaemia
4. Hypocalcaemia (vitamin D and binding protein lost in urine)
5. AKI
125
If the GFR is lowered to stage 1/2 levels can you diagnose CKD on this alone?
No, you also need symptoms or signs of disease.
126
What is the glucose requirement for patients, when prescribing fluids?
When prescribing fluids, the glucose requirement is 50-100 g/day irrespective of the patient's weight
127
What type of renal dysfunction does rhabdomyolysis cause?
Renal tubular necrosis
128
What stage of pregnancy can pre-eclampsia occur?
>20 weeks
129
At what rate should you prescribe fluids?
30 ml/kg/24hr.
130
Tiredness on CKD is commonly caused by what?
Anaemia
131
What conditions cause enlarged kidneys on USS?
HIV associated nephropathy
Autosomal dominant polycystic kidney disease
Diabetic nephropathy
Amyloidosis
132
How does amyloidosis typically present?
Typically 50-65 yrs, with breathlessness and weakness.
Can affect any organ in the body, commonly renal failure, with organomegaly.
133
What are the intrarenal causes of AKI?
Main ones:
1. Acute tubular necrosis
2. Interstitial nephritis
3. Acute Glomerulonephritis
134
How can you use a urine dip to differentiate the causes of AKI?
(May be incomplete)
Nitrites - infection
Protein - Intra-renal cause
Blood - High in Nephritic syndrome (GN)
Leukocytes - high in infection, or in interstitial nephritis
135
What are the 4 phases of sub acute (de quervain's) thyroiditis?
phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR
phase 2 (1-3 weeks): euthyroid
phase 3 (weeks - months): hypothyroidism
phase 4: thyroid structure and function goes back to normal
136
What medications do you usually have to give to kids with turner's syndrome?
Growth Hormone
137
What is acute tubular necrosis?
- Presentation
- Causes
Most common cause of intra-renal AKI.
Presents as:
- AKI
- Muddy brown casts
- Proteinuria on dipstick
Most commonly caused by :
- Renal ischaemia e.g. shock, sepsis
- Toxins: aminoglycosides, rhabdomyolysis, tumour lysis, heavy metals
138
What is Interstitial nephritis?
- Presentation
- Causes
- Complications
One of the causes of AKI (can also cause other renal pathology)
Presents as intra-renal AKI, also:
- Fever, rash, arthralgia
- Hypertension
- Eosinophiluria (immune reaction)
Caused by immune reaction to drugs, such as:
- NSAIDS
Can lead to renal papillary necrosis
- Haematuria
- Flank pain
139
What is acute glomerulonephritis? Presentation?
Presentation:
- Haematuria
- Proteinuria
- Oedema
- Hypertension
- Can present as AKI
- Can present as nephritic syndrome
140
What is glomerulosclerosis? Presentation?
Sclerosis of glomeruli, caused by a dew different conditions
Commonly diabetes and hypertension
141
What is minimal change disease Presentation?
Type of Glomerulonephritis
- presents as nephrotic syndrome.
142
In post renal AKI, what are the causes of obstruction?
Ureters
- Malignancy
- Stone
- Stricture
Bladder
- Malignancy
- Stone
- Neuropathic
Urethral
- Malignancy
- Stone
- BPH
- Stricture
- Infection
- trauma
Catheter
- Sediment
- Clots
143
In post renal AKI, what are the causes of obstruction?
Ureters
- Malignancy
- Stone
- Stricture
Bladder
- Malignancy
- Stone
- Neuropathic
Urethral
- Malignancy
- Stone
- BPH
- Stricture
- Infection
- trauma
Catheter
- Sediment
- Clots
144
Complications of AKI?
Hyperkalaemia
Pulmonary oedema
Acidosis
Uraemia
145
Indications for dialysis?
Hyperkalaemia >7 - resistant to treatment
Pulmonary oedema - resistant to treatment
Metabolic acidosis - pH <7.2
Uraemia - pericarditis, encephalopathy
146
General management strategy for AKI?
Correct fluid balance
Stop nephrotoxic drugs
Treat cause
Manage complications
147
What are the types of glomerulonephritis?
Minimal change.
Diffuse: affecting all glomeruli
Focal: affecting only some of the glomeruli.
Segmental: only affecting parts of an affected glomerulus
148
Treatment of choice for trigeminal neuralgia?
Carbemazepine
149
What are the findings of lateral medullary syndrome?
Wallenberg's syndrome - Inferior posterior cerebellar artery infarct
Ipsilateral
- ataxia,
- nystagmus
- dysphagia
- facial numbness
- cranial nerve palsy e.g. Horner's
Contralateral
- limb sensory loss
150
What are the findings of Weber's syndrome?
Brainstem infarct:
1. ipsilateral III palsy
2. contralateral weakness
151
How do you classify strokes?
Use the three main criteria for anterior circulation.
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
Total anterior circulation (middle and anterior cerebral arteries)
- All three present
Partial anterior circulation (a division of the anterior/middle arteries)
- 2 of the criteria
Posterior circulation stroke, 1 of the following
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
Lacunar infarct (basal ganglia):
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
Then the odd syndromes
- Lateral medullary
- Webers (brainstem)
152
What is a quick and easy bedside test to perform to confirm that fluid is CSF?
Check glucose
(not present in mucous)
153
What is a colles fracture, what structure is commonly damaged?
Fall on outstretched hands, fractures radius
Damages MEDIAN nerve.
154
Basically what does pyramidal and extrapyramidal refer to? (Dr clarke)
Both refer to movement
Extrapyramidal essentially refers to the basal ganglia's role in movement, and their tracts
- Initiation (Direct/indirect)
- Postural reflexes
Pyramidal refers to UMN tracts (corticospinal)
155
Difference in clasped knife and lead pipe rigidity?
Clasped pipe give way
Lead pipe has rigidity the whole way
156
What abnormalities of tone might you find on neurological examination?
Clasped pipe rigidity, lead pipe rigidity, cogwheel rigidity
157
Causes of peripheral neuropathy?
Alcohol
B12 deficiency
CKD
Diabetes and drugs
Every vasculitis
Plus
- Cancer (paraneoplastic)
- Lyme disease
- CHarcot marie tooth
158
What are the cerebellar signs, mnemonic?
DANISH
Dysdiadokinesis
Ataxia
Nystagmus
Intention tremor
Staccato speech - west register street, baby hippopotamus, british constitution.
Hypotonia
159
What do you do to test hand function on examination? (Dr Clarke)
Grip
Pincer grip
Prayer sign
FIne movement (play the piano with your fingers)
160
What muscle is pincer grip testing, what does an abnormal (froments) sign look like?
Adductor policis brevis
frOments (like an O)
161
Why do you do thrombolysis in stroke?
To salvage the ischaemic penumbra
162
SIgns of an ulnar nerve palsy?
Sensory loss over fifth finger and ulnar half of the fourth finger
Weakness and wasting of first dorsal interosseus
163
Weakness in what causes a claw hand?
Weakness of the lumbricals
164
Signs of optic neuropathy?
Pale disc - due to optic atrophy (after optic neuritis)
Loss of visual acuity
Loss of red colour vision
Central scotoma
Afferent pupillary defect
165
Causes of optic neuropathy?
Demyelination
Trauma
Compression (pit tumours)
Ischaemic - diabetes
166
Why do you get sparing of the upper face in UMN lesion?
Bilateral cortical representation
167
Management of bells palsy?
High dose steroids (if within 72hrs)
Eye drops during day
Tape to close eye at night
168
Early parkinsons management?
L dopa
DA agonist if less disabled
- Ropinirole
169
Late PD management?
DA agonists
- Ropinirole
COMT inhibitors
- Entacapone
MAOB inhibitors
- selegiline
170
Sever PD management?
Apomorphine (Non selective DA agonist)
Deep brain stim
171
Treatment of an acute MS attack?
IV methylpred 3 days
172
Signs of a complete occulomotor palsy?
Pupil down and out
Partial ptosis
173
Causes of a complete occulomotor palsy
Diabetes
Posterior communicating artery aneurysm
- usually painful
- if painful RULE THIS OUT
Raised ICP
174
What signs do you get on horners syndrome?
Lack of parasympathetic
Constricted pupil
Slight ptosis
Reduced sweating over forehead
175
SIgns and causes of a sixth nerve palsy?
Failure of abduction (LR6)
Eye is adducted inwards
Can be many things
- Diabetes
- Trauma
- Raised ICP
- MS
- Idiopathic
176
What is myotonic dystrophy? Presentation?
Myotonic dystrophy is an inherited myopathy with features developing at around 20-30 years old.
Autosomal dominant.
Frontal balding
Bilateral ptosis
Cataracts
Dysarthria
177
What is huntington's disease? Presentation and such
Autosomal dominant
Chorea
Personality changes (e.g. irritability, apathy, depression) and intellectual impairment
Dystonia
saccadic eye movements
178
What is Neuroleptic malignant syndrome
- causes
- features
Caused by antipsychotics. Carries 10% mortality rate.
1. pyrexia
2. rigidity
3. tachycardia
179
Treatment of neuroleptic malignant syndrome?
IV fluids, stop drug
Dantrolene (muscle relaxant) or bromocriptine (DA antag)
180
Medications first line for focal and for generalized seizures?
Valproate - generalised
Carbamazepine - focal
181
Treatment for ALS?
Riluzole:
1. Prevents stimulation of glutamate receptors
2. Used mainly in amyotrophic lateral sclerosis
3. Prolongs life by about 3 months
Respiratory care
- non-invasive ventilation (usually BIPAP) is used at night
- studies have shown a survival benefit of around 7 months
182
What is Friedreich's ataxia?
Teenage onset hereditary ataxia. autosomal recessive.
1. absent ankle jerks/extensor plantars
2. cerebellar ataxia
3. optic atrophy
4. spinocerebellar tract degeneration
183
What is astereognosis, what lobe would cause it?
Tactile agnosia - cannot recognise objects from their feel
Parietal lobe
184
What are the two main dystrophinopathies, how are they different?
Duchenne muscular dystrophy
- <5 years
- Learning disability
Becker muscular dystrophy
- > 10 years old
- No learning difficulty
185
What is the ischaemic stroke thrombolysis window?
4.5 hours (when CT scan has excluded haemorrhage)
186
What are the four types of motor neurone disease?
What has the best, and what has the worst prognosis?
ALS (50%)
- LMN signs in arms and UMN in legs
Primary lateral sclerosis
- UMN only
Progressive muscular atrophy
- LMN signs only
- Best prognosis
Progressive bulbar palsy
- Palsy of tongue
- Worst prognosis
187
Features of restless leg syndrome?
- Uncontrollable urge to move legs (akathisia). Symptoms initially occur at night but as condition progresses may occur during the day. Symptoms are worse at rest
paraesthesias e.g. 'crawling' or 'throbbing' sensations
movements during sleep may be noted by the partner - periodic limb movements of sleeps (PLMS)
188
Treatment for restless leg syndrome?
Ropinirole
189
What is ataxic telangiectasia?
Ataxic telangiectasia is an autosomal recessive disorder caused by a defect in the ATM gene which encodes for DNA repair enzymes.
One of the inherited combined immunodeficiency disorders. Other is friedreichs ataxia.
190
Main difference/esiest to differentiate between friedreichs ataxia and ataxic telangiectasia?
Ataxic telangiectasia presents earlier (1-2 years)
191
What is the aetiology of myasthenia gravis?
Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors.
192
What is charcot marie tooth? features?
Hereditary sensorimotor neuropathy
Autosomal dominant
- Features start at puberty
- Distal muscle wasting, pes cavus, clawed toes
- Foot drop, leg weakness often first features
193
What do the lesions of the cerebellar vermis and hemisphere present with?
Vermis presents with ataxic gait
Hemisphere presents with finger-nose ataxia
194
When do you particularly need a CT before LP?
Any evidence of a raised ICP. Need to rule out SOL, if there was a SOL then there is a risk the brain herniates through the foramen magnum.
195
Features of frontotemporal dementia?
Includes Picks disease
Insidious onset
>65 Y/o
Preserved memory and Visuospatial skills
Personality change and conduct problems
196
Radial nerve palsy 'saturday night palsy' presentation?
Wrist drop
Sensory loss to small area between the dorsal aspect of the 1st and 2nd metacarpals
197
Visual hallucinations with dementia most likely diagnosis/
Lewy body Dementia
198
Features of Venous sinus thrombosis?
Headache (may be sudden - but not as much as SAH)
Nausea and vomiting is common in all sinuses
Cavernous sinus
- Periorbital oedema
- Opthalmoplegia
Sagittal sinus
- Seizures
Lateral sinus (transverse)
- 6th nerve palsy
- 7th nerve palsy
199
Dietary intervention in childhood epilepsy?
Ketogenic diet.
200
What are the steps in treating paediatric status epilepticus?
1 Buccal midazolam/ IV lorazepam
2 IV lorazepam
3 IV phenytoin (phenobarbital if already on regular phenytoin)
4 Rapid sequence induction of anaesthesia using thiopental sodium
201
What nerve supplies the extensor campartment of the upper limb?
The radial nerve
202
What nerve provides innervation to the flexor muscles of the upper arm?
Musculocutaneous
- Coracobracialis
- Brachialis
- Biceps brachii
203
What features do you get on a musculocutaneous nerve injury?
Weakness of elbow flexion
Cutaneous sensory loss to the lateral portion of the forearm
204
What does the ulnar nerve innervate (motor)
Flexor carpi ulnaris
(1/2 of flexor digitorum profundus)
Hypothenar eminence
205
What nerves innervate the intrinsic muscles of the hand?
The ulnar nerve does all except:
Thenar and first two lumbricals - Median
206
What nerves innervate the flexor compartment of the arm?
The median nerve, apart from
Flexor carpi ulnaris
(1/2 of flexor digitorum profundus)
207
DVLA driving rules for diagnosed epilepsy, for normal vehicles and for private (group 2) vehicles?
Normal
- Need to be seizure free for 12 months
Group 2 (busses, lorries)
- Need to be seizure free for 10 years
208
How long off driving for unprovoked/isolated seizure?
6 months seizure free
209
DVLA rules for driving in syncope?
simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off
210
Stroke or TIA DVLA driving rules?
4 weeks off
(If multiple TIAs then it's three months)
211
Weakness (e.g. face and arms) in post ictal state, most likely represents what type of epilepsy?
Focal-onset epilepsy
212
Classic signs the diagnosis is MND?
Fasciculations
Mix of UMN and LMN signs
NO sensory signs
213
When starting a phenytoin infusion, what do you need to monitor?
Cardiac monitoring needs to be initiated
214
Features of common peroneal nerve injury?
1. Weakness of foot dorsiflexion
2. weakness of foot eversion
3. weakness of extensor hallucis longus
4. sensory loss over the dorsum of the foot and the lower lateral part of the leg
5. wasting of the anterior tibial and peroneal muscles
215
Important risk factors for MS?
Smoking
Prev. Infectious mononucleosis
Vit D deficiency
FH
216
What is hoffman's sign, what pathology does it illicit?
Flick distal phalanx of middle finger, if positive there is exaggerated flexion of distal phalanx of thumb.
Test for UMN pathology in upper limb
- DCM
- MS
217
When can you stop anti-epileptic drugs?
Can be considered if seizure free >2 years, and you stop them over 2-3 months
218
Trans tentorial (uncle) herniation typically causes what palsy?
Third nerve palsy
219
What is internuclear opthalmoplegia?
Features?
A cause of horizontal disconjugate eye movement
due to a lesion in the medial longitudinal fasciculus, which connects the IIIrd, IVth and VIth cranial nuclei.
Features:
1. Impaired adduction of the eye on the same side as the lesion
2. Horizontal nystagmus of the abducting eye on the contralateral side
MS, vascular disease
220
Supranuclear palsy (Parkinsons plus) cardinal features?
Dysarthria and reduced vertical eye movements
221
Bug often associated with Guillian Barre?
Campylobacter
222
Features of multiple systems atrophy?
1. Parkinsonism
2. Autonomic disturbance (atonic bladder, postural hypotension, erectile dysfunction)
3. Cerebellar signs
223
Classic presentation of idiopathic cranial hypertension?
Obese, young female with headaches / blurred vision
224
In MS what do you use for spasticity, (inc involuntary movements of the leg)?
Baclofen or gabapentin
225
In MS what do you use to treat a relapse?
High dose steroids oral or Iv methylpred
226
What drugs do you use as disease modifying agents in MS?
Beta interferon - if criteria met
Others include
- Glatiramir
- natalizumab
- fingolimod
227
If someone is in status epilepticus what is the first line management?
If you have IV access
- IV Lorazepam
If you don't
- Rectal Diazepam
228
Erbs palsy presents how?
Clinically his arm is hanging loose on the side. It is pronated and medially rotated.
Trauma hx
229
Klumpke's paralysis, what trunks, what presentation?
C8-T1
Horners
Loss of intrinsic muscles of hands
230
What dementia is associated with MND?
Frontotemporal dementia
231
What blood test can be used to differentiate between a pseudo seizure and a true epileptic seizure?
Prolactin (raised after true seizure).
232
Centor criteria for tonsillitis?
3 or more needed.
1. Presence of tonsillar exudate
2. Tender anterior cervical lymphadenopathy or Lymphadenitis
3. History of fever
4. Absence of cough
233
Treatment course length and antibiotic for tonsillitis?
Phenoxymethylpenicillin for 10 days
234
First line investigation in Conns syndrome?
Renin:aldosterone ratio
235
How often are type 1 diabetics recommended to monitor blood sugars?
Type 1
- atl 4 times, inc before each meal and before bed
236
What is a waterlow score used for?
Pressure ulcers
237
First line treatment for long QT syndrome?
Beta blockers - propranolol
238
What is the difference between pityriasis rosea and pityriasis versicolour?
Rosea
- Herald patch, followed by scaly rash
- HHV6/7
Versicolour
- Melassezia yeast infection
- Scaly skin round trunk, neck or arms
- Men in hot humid conditions
239
First line treatment for fungal nail infection?
Oral terbinafine
240
Little's area is on the anterior or posterior nasal septum?
The anterior
241
What foods should those on warfarin avoid?
Foods high in Vit K - broccoli, kale, sprouts, spinach
242
Characteristic features of Prerenal uraemia?
Low urine sodium
High urine osmolality
243
Common causes of peritonitis on peritoneal dialysis?
Staph epidermidis most common, then staph aureus
244
What thyroid dysfunction causes menorrhagia?
Hypothyroidism
245
How do you treat Conns syndrome?
If it's an adrenal adenoma - surgery
If its bilateral adrenocortical hyperplasia - spironolactone
246
What is trousseau's sign?
Hypocalcaemia
Carpal twitching after blood pressure
247
What is Chvostek's sign?
Tapping over parotid causes facial muscles to twitch
248
Urinary findings in acute interstitial nephritis?
Raised white cells and eosinophils
249
Most common type of thyroid cancer?
Papillary
